Basic Information
| Provider Information | |||||||||
| NPI: | 1497405328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAC OF SHELBY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1621 GALLERIA BLVD | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155509400 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387742200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628462590 | ||||||||
| FaxNumber: | 6623987766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | WEISHAAR | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6155509459 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAC ACQUISITION LLC | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 25-5293 | 01 | MS | MEDICARE - SNF | OTHER |